Trying Harder Is the Problem: A Reflection on Helen Macdonald’s “Trust Nature’s Medicine”

A short piece in Psychology Today this spring made an argument worth sitting with. Helen Macdonald, a senior clinical advisor at the British Association for Behavioural and Cognitive Psychotherapies, wrote that the way most people approach insomnia is the thing keeping them awake. The post is under 800 words. The argument under it is the most important reframe in the field.

Here is what she argued, what I think she got right, what I would add, and what it means for the reader who has tried everything.

The argument in five bullets

• Sleep is not a switch-off. It is a highly active biological process the brain runs automatically, the way it runs digestion.
• You cannot get to sleep. You can only fall asleep. The moment you try to make sleep happen, you have broken the conditions it needs to operate.
• Three popular rules make insomnia worse rather than better: needing exactly eight hours, catching up on lost sleep by going to bed early, and using alcohol to fall asleep.
• Two systems govern sleep: the homeostatic drive (sleep pressure built up by adenosine across the day) and the circadian rhythm (the internal 24-hour clock). Chronic insomnia is partly a desynchronization of these two systems.
• Cognitive behavioural therapy for insomnia (CBT-I) is the international first-line treatment, more effective than medication for chronic insomnia.

What’s right, and what’s missing

Macdonald’s central claim is correct, and it is the claim most insomnia sufferers have never heard articulated cleanly. The distinction between getting to sleep and falling into it is the entire mechanism in a sentence. Effort and sleep are mutually exclusive the way effort and yawning are mutually exclusive. You cannot furrow your brow and force a yawn. You can create conditions under which a yawn becomes likely, and then you have to look away and let it happen. Sleep works the same way.

This is the part of CBT-I that most self-help resources fail to deliver, because it runs against every other instinct we have about health. Every other problem responds to more effort. Tired? Sleep more. Anxious? Try harder to relax. Out of shape? Train more. Insomnia is the one condition where the standard cultural advice, which is to try harder and add another protocol to your stack, reliably makes things worse. People who have spent years adding to their wind-down routine, supplementing more aggressively, tracking more obsessively, are not failing at sleep because they haven’t tried enough. They are exhausted by trying, and the trying itself is the wakefulness.

So Macdonald has the diagnosis right. Where the piece needs more is in three places.

The first is the mechanism of why trying keeps you awake. She names intentionality as the trap but doesn’t explain why the trap works. The body has a stress-response system that activates when it perceives a problem to be solved. When you lie down and frame sleep as the problem you must now solve before morning, your sympathetic nervous system gets the message that there is a threat in the room, and it does the only thing it knows how to do. It puts you on alert. Hyperarousal, in the clinical literature, is the sustained activation of this system in people with insomnia. The trying is not metaphorically incompatible with sleep. It is physiologically incompatible.

The second is what the bed has learned. After weeks or months of lying awake trying to sleep, the bed itself becomes a conditioned cue for wakefulness. Walking into the bedroom triggers alertness the way walking into your office triggers a problem-solving mode. This conditioning is invisible to the person experiencing it. They describe it as “my brain turns on the second I lie down,” not realizing the lying down is the cue. Macdonald’s piece doesn’t address this, and without it the reader has no way to understand why the same body that can sleep on a couch cannot sleep in the bed it has slept in for years.

The third is what to do next. Macdonald gestures at sleep window experimentation in a single sentence near the end. For a reader in chronic insomnia, that sentence is not enough. The intervention she is pointing toward, which is sleep restriction or sleep window adjustment, is the single most effective move in CBT-I and the one that benefits most from structured guidance. A reader trying to self-administer it from a paragraph in Psychology Today is unlikely to do it well, and unlikely to do it long enough to see the change.

A case study

A composite. Call her J, in her late forties, in the field for twenty years, the kind of high-functioning professional who has been described as “doing well” by every doctor she has seen.

J has had insomnia for almost a decade. She has tried, in order: melatonin, magnesium, a CBT-I app she completed twice, two sleep trackers, and a brief course of zopiclone she discontinued after six months because it scared her. And more — the supplement drawer, the weighted blanket, the breathing techniques, the $300 mattress topper, the chamomile tea she still drinks out of habit. By the time she books a consult, she has read more about insomnia than most clinicians.

The first thing she says is, “I think I’m the exception. I think nothing will work for me.”

She is wrong, but she has good reasons to think she is right. Every protocol she tried, she tried the same way she is trying now: as a project to push through. The CBT-I app failed not because CBT-I doesn’t work for her but because she ran it like a productivity system. She tracked her sleep efficiency every morning. She got frustrated when the numbers didn’t improve in week two. She added supplements alongside it to maximize the odds. The thing that makes her good at her job is sustained effortful problem-solving, and that is exactly the thing making the treatment fail.

What changed in her case was not adding another technique. It was subtracting the posture. Working with a clinician who held the structure of the sleep window so she didn’t have to track it. Putting the sleep tracker in a drawer for eight weeks. Permission to be uncertain about whether it was working. The shift was from doing CBT-I as a project to doing it as a practice. The numbers followed about five weeks later.

J’s pattern is not rare. It is the most common pattern in the high-functioning insomnia population, and it is the one Macdonald is implicitly speaking to when she names the trap of intentionality. The reader who has tried everything has not failed at insomnia treatment. They have done insomnia treatment the same way they have done everything else in their life, and that approach is the one thing it does not respond to.

What to take from this if you are the reader

If Macdonald’s argument resonates, three things are worth knowing.

First, the failure of every previous attempt is not evidence that you are broken. It is evidence that you have been trying to solve sleep with effort, which is the one tool that doesn’t work on this particular problem. Most of what you tried was designed for a different mechanism than the one driving your insomnia.

Second, self-administered CBT-I is less reliable than clinician-supported delivery. A systematic review of internet-delivered CBT-I found an average dropout rate of 36%, and effect sizes are smaller than for therapist-guided or in-person versions. That gap is not a comment on the treatment. The treatment works. Administering it to yourself, especially if you are the kind of person whose first instinct is to optimize the protocol, is the hard part. Working with a clinician is partly about the clinical knowledge and partly about having someone else hold the structure while you let go of the effort. nih

Third, the path forward is almost always subtraction before it is addition. Removing the tracker. Removing the supplement stack. Removing the extra hour in bed that was supposed to help. The intervention that works is usually less of something, not more. This is the part that is hardest to accept if you have spent years assuming the problem was that you hadn’t yet found the right thing to add.

Macdonald’s piece points at a door. CBT-I, delivered well, is what walks you through it. If you want to talk about whether it fits your situation, you can book a free consultation here.